Medicare Advantage Medical Policy Updates

New Medical Policies

Medical Policy Number:  M.14 

Medical Policy Name: Amniotic Membrane and Amniotic Fluid
Effective Date:  03/01/2026
Preauthorization Required:  No

Codes:  A2001,  A2035, Q4100, Q4132, Q4133, Q4137, Q4138, Q4139, Q4140, Q4145, Q4148, Q4150, Q4151, Q4153, Q4154, Q4155, Q4156, Q4157, Q4159, Q4160, Q4162, Q4163, Q4168, Q4169, Q4170,  Q4171, Q4173, Q4174, Q4176, Q4177, Q4178, Q4180, Q4181, Q4183- Q4192, Q4194, Q4198, Q4199, Q4201, Q4204, Q4205, Q4206, Q4208, Q4209,  Q4211- Q4221,  Q4225,  Q4227,  Q4229 - Q4242,  Q4245- Q4276,  Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4285 - Q4344,  Q4346  Q4373, Q4375,  Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394, Q4395, Q4396, Q4397, V2790, 65778. 65779, 65780

Summary: Only specific products will be allowed; all others will be considered non-covered on  CMS (01/01/2026) and Updated Policy Statement
Policy Statement:

Diabetic foot ulcers (LCD L38682)
Initial Treatment

1. The initial 1-4 applications with treatment using human amniotic membrane for the following indications may be considered reasonable and necessary when the following LCD criteria are met:
   1. Diagnosis of chronic non-infected diabetic foot ulcers AND
   2. Assessment of Type 1 or Type 2 diabetes and management history to include comorbidities, current glucose levels/A1C, diet and nutritional status, skin assessment, use of appropriate footwear and/or use of mechanically supportive devices designed to reduce or eliminate pressure on wound sites AND
   3. Documented comprehensive assessment, diagnostic tests and treatment plan AND 
   4. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND
   5. Standard of treatment therapy failed to achieve at least 50% ulcer area reduction  AND
   6. Documentation of patient compliance with treatment plan  AND 
   7. One of the following products is utilized:
   • Grafix Prime (Q4133)
   • Affinity (Q4159)
   • NuShield (Q4160) 
   • Epicord (Q4187)
   • Amnioband or Guardian (Q4151)
   • Epifix (Q4186)
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740.
3. The use of human amniotic membranes is considered not reasonable and necessary when the above criteria are not met.

Ongoing Treatment

1. Additional 5-8 applications with treatment using human amniotic membrane for the following indications may be considered reasonable and necessary when the following LCD criteria are met:
   1. Application is within 16 weeks of the first application  AND
   2. Measurable decreased size or depth of the ulcer OR 
   3. Evidence of tissue granulation, epithelialization or progress towards closure AND
   4. One of the following products is utilized:
      • Grafix Prime (Q4133)
      • Affinity (Q4159)
      • NuShield (Q4160) 
      • Epicord (Q4187)
      • Amnioband or Guardian (Q4151)
      • Epifix (Q4186)                            
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740
3. The use of human amniotic membranes is considered not reasonable and necessary when the above criteria are not met.

Venous leg ulcers
Initial Treatment 

1. The initial 1-4 applications with treatment using human amniotic membrane for the following indications may be considered reasonable and necessary when the following LCD criteria are met:
   1. Diagnosis of Chronic non-infected venous leg ulcers AND
   2. Adequate control of systemic disease and any exacerbating or comorbid factors AND
   3. Documented comprehensive assessment, diagnostic tests and treatment plan AND
   4. Use of firm strength compression garment (greater than 20mmHG) or multi-layered compression dressings AND
   5. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND
   6. Ulcers persist AND
   7. Documentation of patient compliance with treatment plan
   8. One of the following products is utilized:
      • Oasis Wound Matrix (Q4102)
      • Amnioband or Guardian (Q4151)
      • Epifix (Q4186)
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740
3. The use of human amniotic membranes is considered not reasonable and necessary when the above criteria are not met.

Ongoing Treatment

1. Additional 5-8 applications with treatment using human amniotic membrane for the following indications may be considered reasonable and necessary when the following LCD criteria are met:
   1. Application is within 16 weeks of the first application  AND
   2. Measurable decreased size or depth of the ulcer OR 
   3. Evidence of tissue granulation, epithelialization or progress towards closure AND
   4. One of the following products is utilized:
      • Oasis Wound Matrix (Q4102)
      • Amnioband or Guardian (Q4151)
      • Epifix (Q4186)
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740
3. The use of human amniotic membranes is considered not reasonable and necessary when the above criteria are not met.

Other indications

1. The applications with treatment using human amniotic membrane for the following indications may be considered medically necessary when the following criteria are met:
   1. Neurotrophic keratitis with ocular surface damage and inflammation that does not respond to conservative therapy OR
   2. Corneal ulcers and melts that do not respond to initial medical therapy. when there is insufficient healthy tissue to create a conjunctival autograft. OR
   3. Pterygium repair when there is insufficient healthy tissue to create a conjunctival autograft  OR
   4. Stevens-Johnson syndrome of the eye OR
   5. Persistent epithelial defects of the eye and ulceration that do not respond to conservative therapy AND
   6. One of the following products is utilized:
      1. Affinity^®(Q4159)
      2. AmnioBand^® Membrane (Q4151)
      3. Biovance^®
      4. EpiCord^® (Q4187)
      5. EpiFix^® (Q4186)
      6. Grafix™
      7. NuShield^® (Q4160)                         
2. The use of human amniotic membranes is considered not reasonable and necessary when the above criteria are not met.
3. The use of human amniotic fluid injection is not medically necessary for all indications.

Medical Policy Number:  M.29

Medical Policy Name: Benign Prostate Hyperplasia
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Codes: 52510 37243 55873 52601 53850 55880 55899 52649 52647 53865 53866 53852 0421T 53854
Policy Statement:

Urolift 

1. Use of prostatic urethral lift in individuals with moderate-to-severe lower urinary tract obstruction due to benign prostatic hyperplasia may be considered medically necessary when ALL the following criteria are met: 
   1.  Age 45 years or older  AND
   2. The patient has persistent or progressive lower urinary tract symptoms despite medical therapy (α1-adrenergic antagonists maximally titrated, 5α-reductase inhibitors, or combination medication therapy maximally titrated) over a trial period of no less than 6 months, or is unable to tolerate medical therapy; AND
   3. Prostate gland volume is ≤80 mL; AND
   4. Prostate anatomy demonstrates normal bladder neck without an obstructive or protruding median lobe; AND 
   5. Patient does not have urinary retention (post void residual of less than 200ml), urinary tract infection, or recent prostatitis (within past year); AND
   6. Patients have had appropriate testing to exclude diagnosis of prostate cancer; AND
   7. Patient does not have a known allergy to nickel, titanium, or stainless steel AND
   8. Absence of ALL the following: 
      1. Urethra conditions that may prevent insertion of delivery system 
      2. Urinary tract infection 
      3. Urinary incontinence 
      4. Current gross hematuria 
      5. Individual reports nickel, titanium, or stainless-steel allergy  
2. Use of prostatic urethral lift in other situations is considered not reasonable and necessary.
3. Repositioning of the stents or repeat procedures will be reviewed for medical necessity.

Water Vapor Therapy 

1. Water vapor therapy (e.g., Rezum) may be considered reasonable and necessary when the following criteria are met: 
   1. International Prostate Symptom Score (IPSS) of 12 or higher;  AND 
   2. Failure or inability to tolerate maximally titrated medical therapy (α1-adrenergic antagonists, 5α-reductase inhibitors, or combination medication therapy) over a trial period of no less than 3 months; AND
   3. Imaging shows prostate gland volume is greater than 30 ml and less than or equal to 80 mL; AND
   4. The individual does not have any of the following: 
      1. Urinary tract infection being actively treated; OR 
      2. Prostatitis being actively treated; OR 
      3. Known or suspected prostate cancer
2. Water vapor therapy is not medically necessary for all other indications.  

Transurethral waterjet ablation  (LCD L38682 Effective 12/14/2025)

1. Transurethral waterjet ablation (AquaBeam System) may be reasonable and necessary ONCE per lifetime in patients with:  
   1. All the following indications:
      1. PROSTATE volume of 30-150ml
      2. Persistent moderate to severe symptoms despite maximal medical management including ALL of the following:
         1. International Prostate Symptom Score (IPSS) ≥12
         2. Maximum urinary flow rate (Qmax) of ≤15 mL/s
         3. Failure, contraindication or intolerance to at least 3 months of conventional medical therapy for LUTS/BPH (e.g., alpha blocker, PDE5 Inhibitor, finasteride/dutasteride)
   2. Only treatment using an FDA approved/cleared device will be considered reasonable and necessary.
2. Transurethral waterjet ablation (AquaBeam System) is considered not medically necessary when the above criteria are not met.  
3. Transurethral waterjet ablation of the prostate is not considered reasonable and necessary for patients with the following:
   1. Body mass index ≥ 42kg/m2
   2. Known or suspected prostate cancer (based on NCCN Prostate Cancer Early Detection guidelines4) or a prostate specific antigen (PSA) >10 ng/mL unless the patient has had negative prostate biopsy within the last 6 months.
   3. Bladder cancer, neurogenic bladder, bladder calculus or clinically significant bladder diverticulum
   4. Active urinary tract or systemic infection
   5. Treatment for chronic prostatitis
   6. Diagnosis of urethral stricture, meatal stenosis, or bladder neck contracture
   7. Damaged external urinary sphincter
   8. Known allergies to device materials
   9. Inability to safely stop anticoagulants or antiplatelet agents preoperatively.

Other Therapies for Benign Prostatic Hyperplasia (BPH)

1. The following procedures are considered not reasonable or necessary as their clinical effectiveness has not been established.  
   1. Endoscopic balloon dilation of the prostatic urethra  (52510)
   2. Prostatic arterial embolization (PAE)  (37243)
   3. Cryosurgical ablation for the treatment for BPH  (55873) 
   4. Plasma Kinetic Vaporization (e.g., PlasmaKinetic™ Tissue Management System)  (52601)  
   5. Water-induced thermotherapy (WIT) (also known as hot-water balloon thermoablation and thermourethral hot-water therapy) (53850)
   6. Absolute ethanol injections. 
   7. High-intensity focused ultrasound (HIFU) for benign prostatic hyperplasia (BPH) (55880)
   8. Histotripsy (Vortx Rx System) (55899)
   9. Interstitial laser coagulation (ILC) (52649)
   10. Transrectal thermal therapy (53850)
   11. Transurethral ultrasound-guided laser incision of the prostate (TULIP) (52647)
   12. ITind device implant (53865 53866)
   13. Radiofrequency Thermotherapy (53852) 

Medical Policy Number:  M.30

Medical Policy Name: Single Chamber and Dual Chamber Permanent Cardiac Pacemaker and Defibrillators
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Codes: 33202 33203  33206, 33207, 33208, 33215 33216 33217 33218 33220 33223 33224 33225 33230 33231 33240 33241 33243 33244 33249 33262 33263 33264 33270 33271 33272 33273

Policy Statement:

1. The Single Chamber and Dual Chamber Permanent Cardiac Pacemakers may be considered reasonable and necessary when the following indications are met:
   1. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction AND
   2. Documented non-reversible symptomatic bradycardia due to second degree and/or third-degree atrioventricular block
2. Services are not reasonable and necessary when the above criteria are not met. 
3. The following indications are considered non-covered for implanted permanent single chamber or dual chamber cardiac pacemakers per  NCD 20.8.3 
   • Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia,
   • Asymptomatic first-degree atrioventricular block,
   • Asymptomatic sinus bradycardia,
   • Asymptomatic sino-atrial block or asymptomatic sinus arrest,
   • Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without symptomatic bradycardia,
   • Asymptomatic second-degree atrioventricular block of Mobitz Type I unless the QRS complexes are prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His Bundle (a component of the electrical conduction system of the heart),
   • Syncope of undetermined cause,
   • Bradycardia during sleep,
   • Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) without syncope or other symptoms of intermittent atrioventricular block,
   • Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker drug therapy,
   • Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the control of tachycardia, and
   • A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated with a reasonable likelihood that pacing needs will become prolonged.

Implantable Cardioverter Defibrillator 
NCD 20.4
Ventricular tachyarrhythmia (VT) or Cardiac arrest 

1. Implantable Cardioverter Defibrillator may be considered reasonable and necessary when the following criteria are met per NCD 20.4.
   A. Personal history of sustained ventricular tachyarrhythmia (VT) or cardiac arrest due to ventricular fibrillation (VF) AND
   B. The Patient is clinically stable AND
   C. The sustained VT episode was not associated with a myocardial infarction and not due to a transient or reversible cause OR
   D. The cardiac arrest episode due to ventricular fibrillation was not due to transient or reversible cause
2. Services are not reasonable and necessary when the above criteria are not met. 

Myocardial Infarction

1. Implantable Cardioverter Defibrillator may be considered reasonable and necessary when the following criteria are met per NCD 20.4.
   1. Previous Myocardial infarction and documented left ventricular ejection fraction  ≤ 0.30  (must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac magnetic resonance imaging (MRI), or catheter angiography) AND
   2. The patient is clinically stable AND
   3. The patient has not had any of the following:
      • New York Heart Association (NYHA) classification IV heart failure
      • Had a coronary artery bypass graft (CABG), or percutaneous coronary intervention (PCI) with angioplasty and/or stenting, within the past 3 months
      • Had an MI within the past 40 days 
      • Clinical symptoms and findings that would make them a candidate for coronary revascularization.
      • Significant, irreversible brain damage
      • Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival in less than 1 year
      • Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
2. Services are not reasonable and necessary when the above criteria are not met. 

Ischemic, Dilated Cardiomyopathy 

1. Implantable Cardioverter Defibrillator may be considered reasonable and necessary when the following criteria are met per NCD 20.4
   1. Severe, ischemic dilated cardiomyopathy with no personal history of sustained VT or cardiac arrest due to VF AND
   2. NYHA Class II or III heart failure AND
   3. Left ventricular ejection fraction ≤ 35% (must be measured by  echocardiography, radionuclide (nuclear medicine) imaging, cardiac magnetic resonance imaging (MRI), or catheter angiography). AND
   4. The Patient is clinically stable AND
   5. The patient has none of the following:
      • Had a CABG, or PCI with angioplasty and/or stenting, within the past 3 months
      • Had an MI within the past 40 days
      • Clinical symptoms and findings that would make them a candidate for coronary revascularization.
      • Significant, irreversible brain damage
      • Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival in less than 1 year
      • Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
2. Services are not reasonable and necessary when the above criteria are not met. 

Non ischemic dilated cardiomyopathy

1. Implantable Cardioverter Defibrillator may be considered reasonable and necessary when the following criteria are met per NCD 20.4
   1. Severe, non- ischemic dilated cardiomyopathy with no personal history of sustained VT or cardiac arrest due to VF AND
   2. NYHA Class II or III heart failure AND
   3. Left ventricular ejection fraction ≤ 35%. (must be measured by  echocardiography, radionuclide (nuclear medicine) imaging, cardiac magnetic resonance imaging (MRI), or catheter angiography) AND
   4. The Patient has  been on optimal medical therapy for at least 3 months AND
   5. The Patient is clinically stable AND
   6. The patient has none of the following:
      • Had a CABG, or PCI with angioplasty and/or stenting, within the past 3 months
      • Had an MI within the past 40 days
      • Clinical symptoms and findings that would make them a candidate for coronary revascularization.
      • Significant, irreversible brain damage
      • Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival in less than 1 year
      • Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
2. Services are not reasonable and necessary when the above criteria are not met. 

Familial or Genetic Disorder 

1. Implantable Cardioverter Defibrillator may be considered reasonable and necessary when the following criteria are met per NCD 20.4
   1. Documented familial or genetic disorders with a high risk life-threatening tachyarrhythmias, including but not limited to long QT syndrome, or hypertrophic cardiomyopathy AND
   2. The Patient is clinically stable AND
   3. The Patient does not have any of the following:
      • Significant, irreversible brain damage
      • Any disease, other than cardiac disease (e.g., cancer, renal failure, liver failure) associated with a likelihood of survival less than 1 year
      • Supraventricular tachycardia such as atrial fibrillation with a poorly controlled ventricular rate.
2. Services are not reasonable and necessary when the above criteria are not met. 

Replacement ICD
Replacement of an existing ICD may be considered reasonable and necessary when due to the end of battery life, elective replacement indicator (ERI) or device/lead malfunction

Medical Policy Number:  M.31

Medical Policy Name: Electrophysiology Testing  and Cardiac Ablation
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Codes: 93600, 93602, 93603, 93609, 93610, 93612, 93613, 93618, 93619, 93620, 93624, 93650, 93653, 93654, 93656
Policy Statement:

Interqual Criteria will be utilized:  Electrophysiology (EP) Testing +/- Catheter Ablation, Cardiac 

Medical Policy Number:   M.32 

Medical Policy Name: Non-Coronary Vascular Stents
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Codes:  37236, 37237, 37238, 37239, 37254, 37255, 37256, 37257, 37258, 37259, 37260, 37261, 37262, 37263, 37264, 37265, 37266, 37267, 37268, 37269, 37270, 37271, 37272, 37273, 37274, 37275, 37276, 37277, 37278, 37279, 37280, 37281, 37282, 37283, 37284, 37285, 37286, 37287, 37288, 37289, 37290, 37291, 37292, 37293, 37294, 37295, 37296, 37297, 37298, 37299
Summary:
Above codes are effective 01/01/2026
The criteria utilized will be from LCD L35998 and A57590

Medical Policy Number:   M.34

Medical Policy Name:  Orthognathic Surgery
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Codes:  
Policy Statement 
Orthognathic Surgery may be considered reasonable and necessary for correction of skeletal deformities of the maxilla or mandible when all the following are met: (1) skeletal dysfunction precludes adequate treatment by dental therapeutics and orthodontics alone, and (2) there is functional impairment, and (3) there is clinical documentation of orthodontic therapy to align the teeth prior to orthognathic surgery where appropriate.

Skeletal Dysfunction

1. Anterior-Posterior discrepancies defined by one of the following:
   1. Incisor Relationship
      a. Horizontal overjet  ≥ 5 mm, OR
      b. Overjet 0 mm or negative (reverse overjet)
                      OR
   2. Molar Relationship
      
      1. Anteroposterior discrepancy of  ≥ 4 mm between maxillary and mandibular molars
         OR
2. Vertical Discrepancies defined by one of the following:
   1. Two or more standard deviations from published norms  for accepted skeletal landmarks  OR 
   2. Open bite, defined as: 
      1. No vertical overlap of anterior teeth, OR
      2. Unilateral or bilateral posterior open bite greater than 2 mm  OR 
   3. Deep overbite causing impingement or irritation of buccal or lingual soft tissues of the opposing arch OR 
   4. Super-eruption of a dentoalveolar segment due to lack of occlusion
      OR
3. Transverse discrepancies defined by one of the following:
   1. Two or more standard deviations from published norms  OR
   2. Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4mm or greater, or a unilateral discrepancy of 3mm or greater, given normal axial inclination of the posterior teeth.
       OR
4. Asymmetries defined by the following:
   1. Anteroposterior, transverse, or lateral asymmetries greater than 3mm with concomitant occlusal asymmetry. 
      AND

1. Masticatory dysfunction due to skeletal deformity (e.g., inability to incise or chew solid foods, loss of food through the lips, intra-oral trauma to soft tissue during chewing), OR
2. Swallowing dysfunction (dysphagia) due to skeletal deformity (e.g., choking on incompletely chewed solid foods); OR
3. Speech impairments (documentation from speech pathologist or speech therapist required) due to severe cleft deformity or skeletal malocclusion that do not respond to orthodontia or speech therapy, OR
4. Persistent myofascial pain despite conservative treatment with physical therapy and splints.  

2. Maxillofacial surgery, including mandibular-maxillary advancement (MMA) may be considered reasonable and necessary for obstructive sleep apnea and upper airway resistance syndrome when ALL the following criteria are met:
   1. Adults age  ≥ 21 years AND
   2. AHI  ≥20 with less than 20% central apneas AND
   3. Trial and failure or intolerance of CPAP AND
   4. No other surgical options are recommended 
3. Orthognathic surgery is considered not reasonable and necessary when the above criteria have not been met
4. Orthognathic surgery performed for the following indications is considered not reasonable or necessary:
   • correction of articulation disorders and other distortion of sibilant sound class (hissing sound) because these distortions do not cause functional impairment
   • Persistent myofascial pain despite conservative treatment with physical therapy and splints 
   • Condylar positioning devices because their effectiveness has not been established
   • 3-D virtual treatment planning or computer-aided three-dimensional simulation and navigation in orthognathic surgery (CASNOS) for orthognathic surgery  because its effectiveness has not been established
5. Orthognathic surgery is considered cosmetic for the following indications
   • When performed for aesthetic/cosmetic impairments with or without psychological symptoms
   • Genioplasty (surgery of the chin to correct a receding chin with an implant or reduce a prominent chin) when performed in conjunction with orthognathic surgery, for the sole purpose of improving appearance and/or profile.

1. Clinical notes with medical history, physical exam, description of skeletal deformity; and
2. Panorex and cephalometric radiographs; and
3. Cephalometric tracings and analysis; and
4. Anterior and posterior radiographs for asymmetrical deformities; and
5. Medical records from treating physician documenting evaluation, diagnosis, and previous management of the functional impairments; and
6. Photographs that demonstrate skeletal deformity

Medical Policy Number:   M.35 

Medical Policy Name:  Urinary Incontinence Treatment
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Codes:   53451, 53452, 53453, 53454, 51715 L8603 L8604 L8606
Policy Statement:

Adjustable Balloon Continence Devices

1. The Permanent Adjustable Balloon Continence Devices (e.g. ACT and ProACT therapy system) for females and males are considered not reasonable and necessary for the treatment of urinary incontinence because its effectiveness has not been established.

Periurethral bulking agents

1. The use of carbon-coated spheres, calcium hydroxylapatite, polyacrylamide hydrogel, or polydimethylsiloxane Injection of periurethral bulking agents may be considered reasonable and necessary when the individual has stress urinary incontinence who meet the following criteria:
   1. The incontinence is due to trauma or injury OR 
   2. Both of the following criteria are met:
      1. The incontinence persists despite at least 12 weeks of conservative treatment ( pelvic floor muscle exercises and behavioral changes, such as fluid management and moderation of physical activities that provoke incontinence) AND
      2. One of the following:
         1. The incontinence is caused by intrinsic sphincter deficiency (ISD), OR
         2. The incontinence is due to urethral hypermobility in individuals with abdominal leak point less than 100 cm H2O.
2. A Repeat injection of periurethral bulking agents may be considered reasonable and  necessary for individuals who meet the medical necessity criteria for initial injection and have persistent incontinence after the initial injection.
3. Injection of periurethral bulking agents is not reasonable and necessary when the above criteria are not met. 

Medical Policy Number:   M.36 

Medical Policy Name: Non-invasive Cerebrovascular and peripheral arterial vascular studies 
Effective Date:  03/01/2026
Preauthorization Required:  No
Codes:  93880 93882 93886 93888 93892 93893 93895 93922 93923 93924 93925 93926 93930 93931
Summary:

The criteria utilized will be from LCD L35753, A57592 and L35761, A57593

Medical Policy Number:   M.37

Medical Policy Name:  Echocardiogram, Transthoracic (TTE) and Transesophageal (TEE)
Effective Date:  03/01/2026
Preauthorization Required:    Echocardiogram, Transthoracic (TTE) PA not required  and Transesophageal (TEE) PA required 
Codes:  76376, 76377, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93319, 93320, 93325, 93351, 93352, 93355
Summary:

InterQual criteria will be utilized:  Echocardiogram, Transthoracic (TTE) and Transesophageal (TEE)

Medical Policy Number:   M.41

Medical Policy Name:  Prostate Rectal Spacers
Effective Date:  03/01/2026
Preauthorization Required:   Yes
Code:  55874
Policy Statement:

1. Prostate rectal spacers (eg. SpaceOAR system) may be considered medically necessary when ALL following criteria are met:
   1. The patient has a diagnosis of localized or locally advanced prostate cancer (Stage I -III) with no lymph node involvement AND
   2. The patient will undergo hypofractionated radiation therapy (hypofractionated-IMRT, hypofractionated high dose rate brachytherapy, hypofractionated EBRT,  or stereotactic body radiotherapy) AND
   3. The prostate volume is less than 80 cc AND
   4. The patient has had no prior surgery or radiation for prostate cancer treatment AND
   5. the patient has no active bleeding or platelet count <100×10(9)/l, an international normalized ratio >1.5, or activated partial thromboplastin time >50 seconds AND
   6. There is no tumor invasion into the rectum and no posterior extraprostatic extension (local tumor growth beyond the fibromuscular pseudocapsule of the prostate gland into the periprostatic soft tissues
2. Prostate rectal spacers is not medically necessary when the above criteria are not met.

 

Revised Medical Policies

Medical Policy Number:  M.3

Medical Policy Name: Bioengineered Skin and Soft Tissue Substitutes
Effective Date:  03/01/2026
Preauthorization Required:  No
Codes:  15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, 15271, 15272,15273, 15274, 15275, 15276, 15277, A2002, A2003, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2017, A2018, A2019, A2020, A2021, A2029, A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2039, A4100, C1832, C1849, C9354, C9356, C9360, C9363, C9364, Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4116, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4130, Q4134, Q4135, Q4136, Q4141, Q4142, Q4143, Q4146, Q4147, Q4149, Q4152, Q4158, Q4161, Q4164, Q4165, Q4167, Q4175, Q4182, Q4193, Q4195, Q4196, Q4197, Q4200, Q4202, Q4203, Q4220, Q4226
Summary:  Only specific products will be allowed, all others will be considered non-covered by CMS (01/01/2026)
Policy Statement:

Initial Treatment

1. The initial 1-4 applications with treatment using bioengineered skin substitutes for the following indications are reasonable and necessary when the following LCD criteria are met:
   1. Diagnosis of chronic non-infected diabetic foot ulcers AND
   2. Assessment of Type 1 or Type 2 diabetes and management history to include comorbidities, current glucose levels/A1C, diet and nutritional status, skin assessment, use of appropriate footwear and/or use of mechanically supportive devices designed to reduce or eliminate pressure on wound sites AND
   3. Documented comprehensive assessment, diagnostic tests and treatment plan AND 
   4. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND
   5. Standard of treatment therapy failed to achieve at least 50% ulcer area reduction  AND
   6. Documentation of patient compliance with treatment plan AND 
   7. One of the following products is utilized:
      • Kerecis Omega3 Marigen Shield (A2019)   
      • Integra Dermal or Integra Omnigraft Dermal (Q4105)  
      • Graftjacket (Q4107) 
      • Primatrix (Q4110) 
      • Theraskin (Q4121) 
      • Dermacell (Q4122) 
      • Flex HD or Allopatch HD (Q4128) 
      • Kerecis Omega  (Q4158)   
      • Derma-Gide (Q4203)
      • Apligraf (Q4101)
      • Dermagraft (Q4106)
      • Oasis Wound Matrix (Q4102)
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740
3. The use of bioengineered skin substitutes is considered not reasonable and necessary when the above criteria are not met.

Ongoing Treatment

1. Additional 5-8 applications with treatment using bioengineered skin substitutes for the following indications are reasonable and necessary when the following LCD criteria are met:
   1. Application is within 16 weeks of the first application  AND
   2. Measurable decreased size or depth of the ulcer OR 
   3. Evidence of tissue granulation, epithelialization or progress towards closure 
   4. One of the following products is utilized:
      • Kerecis Omega3 Marigen Shield (A2019)   
      • Integra Dermal or Integra Omnigraft Dermal (Q4105)  
      • Graftjacket (Q4107) 
      • Primatrix (Q4110) 
      • Theraskin (Q4121) 
      • Dermacell (Q4122) 
      • Flex HD or Allopatch HD (Q4128) 
      • Kerecis Omega  (Q4158)   
      • Derma-Gide (Q4203)
      • Apligraf (Q4101)
      • Dermagraft (Q4106)
      • Oasis Wound Matrix (Q4102)
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740
3. The use of bioengineered skin substitutes is considered not reasonable and necessary when the above criteria are not met.

Venous leg ulcers
Initial Treatment 

1. The initial 1-4 applications with treatment using bioengineered skin substitutes for the following indications are reasonable and necessary when the following LCD criteria are met:
   8. Diagnosis of Chronic non-infected venous leg ulcers AND
   9. Adequate control of systemic disease and any exacerbating or comorbid factors AND
   10. Documented comprehensive assessment, diagnostic tests and treatment plan AND
   11. Use of firm strength compression garment (greater than 20mmHG) or multi-layered compression dressings AND
   12. Standard treatment/conservative measures were provided for a minimum of 4 weeks with documented compliance AND
   13. Ulcers persist AND
   14. Documentation of patient compliance with treatment plan
   15. One of the following products is utilized:
       • Dermagraft (Q4106)
       • Oasis Wound Matrix (Q4102)
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740
3. The use of bioengineered skin substitutes is considered not reasonable and necessary when the above criteria are not met.

Ongoing Treatment 

1. Additional 5-8 applications with treatment using bioengineered skin substitutes for the following indications are reasonable and necessary when the following LCD criteria are met:
   1. Application is within 16 weeks of the first application  AND
   2. Measurable decreased size or depth of the ulcer OR
   3. Evidence of tissue granulation, epithelialization or progress towards closure
   4. One of the following products is utilized:
      • Dermagraft (Q4106)
      • Oasis Wound Matrix (Q4102)
2. The use of any other product is considered non-covered by CMS LCD L39865 and A59740
3. The use of bioengineered skin substitutes is considered not reasonable and necessary when the above criteria are not met.

Other indications

The use of bioengineered skin substitutes for breast reconstruction is reasonable and necessary when the following criteria are met:

1. There is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required, AND
2. There  is viable but compromised or thin postmastectomy skin flaps that are at risk of dehiscence or necrosis, OR
3. The inframammary fold and lateral mammary folds have been undermined during mastectomy and reestablishment of these landmarks is needed. AND
4. One of the following products is utilized: 
   • Allowmax
   • Dermacell
   • DermaMatrix
   • FlexHD
   • FlexHD Pilable
            OR 
5. Dystrophic epidermolysis bullosa AND
6. The following product is utilized:
   • OrCel 
             OR
7. Second- or third-degree burns AND
8. One of the following products is utilized:
   • Epicel  (when the burns comprise a total body surface area of greater than 30%)
   • Integra Dermal Regeneration Template

2. The use of any other product is considered not reasonable and necessary
3. The use of bioengineered skin and soft tissue substitutes is not reasonable and necessary for all other indications.

Medical Policy Number:  M.5

Medical Policy Name: MA Cosmetic and Reconstructive Surgery 
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Summary:  codes being added 
Codes: 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11971,  15775, 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15794, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15876, 15878, 15879, 17340, 17360, 17380, 19300, 19364, 19370, 19396, 69300

The criteria utilized will be from NCD 250.5, NCD 140.2  LCD 39051

Medical Policy Number:  M.5

Medical Policy Name: MA Cosmetic and Reconstructive Surgery 
Effective Date:  03/01/2026
Preauthorization Required:  Yes
Summary:  Adding Tissue Transfer Flaps 
Codes: 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 14350, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15730, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15922, 15934, 15936, 15944, 15946, 15952, 15956, 49904, 49905
Policy Statement:  

Interqual Criteria will be utilized for the above codes 

Medical Policy Number:  M.13

Medical Policy Name:  MA Radiology 
Effective Date:  03/01/2026  
Preauthorization Required:  Yes
Summary:  
Interqual Criteria will be utilized for the following codes:  76377, 76498, 78012, 78013, 78014, 78070, 78075, 78185, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78278, 78290, 78291, 78579, 7470, 78597, 78598, 78601, 78606, 78610, 78635, 78645, 78650, 78660, 78699, 78700, 78701, 78707, 78708, 78709, 78740, 78761, 78801, 78830, 78831, 78832, A9586, Q9983, S8092

 NCD and LCD will be utilized for the following codes: 
 75580 to follow LCD L38839
 78071, 78072, 78803 to follow NCD 220.12
 93978, 93979 to follow LCD  L35755
 C8931, C8932, C8933, C8934, C8935, C8936 to follow NCD 220.2
 A9552 to follow NCD 220.6.13, 220.6.8, 220.6.9 or IQ 
 A9601 to follow 220.6.13

Medical Policy Number:  M. 15

Medical Policy Name:  MA Procedures Following NCD, LCD or Interqual
Effective Date:  03/01/2026  
Preauthorization Required:  Yes
Summary:   
Adding
81279, 81338, 81339, 0027U, 0040U to follow LCD L40022 
E0746, 90875, 90876 90901 to follow NCD 30.1
90912, 90913 to follow NCD 30.1.1
L8606 to follow NCD 230.10
E0740 to follow NCD 230.8
E1399 to follow NCD 150.2, LCD L33794 and L33794

Medical Policy Name:  Evolent Joint Surgeries

Effective Date:  03/01/2026
Preauthorization Required:   Yes
Codes:  27132, 27134, 27137, 27138, 27130 S2118, 29914, 29915, 29916, 29860, 29861, 29862, 29863, 27486, 27487, 27447, 27446, 27438, 27570,29884, 27405, 27407, 27409, 27427, 27428, 27429, 29888, 29889, 27332, 27333, 27403, 29868, 29880, 29881,29882, 29883, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 29866, 29867, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29885, 29886, 29887, G0289, 23473, 23474, 23472, 23470, 29825, 29806, 23450,23455, 23460, 23462, 23465, 23466, 29807, 23410, 23412, 23420, 29827, 23120, 23125, 23130, 23405, 23415, 23430, 23700, 29805, 29819,29820,29821, 29822, 29823, 29824, 29825, 29826, 29828

Policy Statement:

Prior Authorizations will be performed by Evolent